Political Geography of the UK (with special reference to healthcare issues)

What is the “United Kingdom”?

“Great Britain” refers to England, Scotland (Alba in Gaelic) and Wales (Cymru in Welsh) inclusive of the 6,289 islands that come within their individual jurisdictions.

“Northern Ireland” is all that part of the island of Ireland that did not become wholly independent in December 1921. The province is sometimes called “The Six Counties” or Ulster, but the borders of historic Ulster differ from the borders of Northern Ireland so this can be misleading.

The United Kingdom is Great Britain plus Northern Ireland.

It does not include...
The Republic of Ireland, also called Éire or Poblacht na hÉireann in Irish Gaelic;The Isle of Man, also called Ellan Vannin in the Manx language;The Channel Islands, also called Îles de la Manche in the local dialect of French...
but does include other islands such as the Inner and Outer Hebridies (Na h-Eileanan an Iar, which translates from Scottish Gaelic as “The Western Isles”), the Orkney Islands, the Shetland Islands, the Isle of Wight, the Scilly Isles, Lundy and Rathlin Island (Reachlainn). It is a complex situation involving jealously guarded cultural, religious and linguistic differences that have, over many centuries, given rise to various armed conflicts, insurgencies and political assassinations.

A cynic might say that the term “United” is wishful thinking rather than a statement of fact. Yet, in the face of an external threat, unity asserts itself.

The United Kingdom is currently involved in a process known as “devolution”, whereby certain governmental powers are being transferred from the UK parliament at Westminster to parliaments or assemblies in Wales, Scotland and Northern Ireland. The executive functions are being devolved in line with the transfer of legislative powers. The objective of devolution is to relieve societal stress in situations where greater self-determination is demanded, without going as far as full secession and the break-up of the United Kingdom. The recent referendum on the subject of full independence for Scotland didn't go for independence, but this probably isn't the end of the story.

So what is the relevance of all this to circumcision?

One of the powers already devolved is the administration of healthcare. It would, for example, be entirely possible for the different administrations to adopt different policies regarding the promotion and funding of elective circumcision. Any pressure for change must, therefore, be applied in more than one forum. Even at ministerial level, there is no single point of contact applicable to the whole of the UK in respect of health issues.

Reorganisation of the structure of the NHS in England (only) introduced major administrative changes on/from 1st April 2013. Of particular relevance has been the transfer of Public Health issues (such as stop-smoking campaigns) from the NHS to Local Authorities. Nothing new here; it merely restores the situation that prevailed up until 1974. Notable past successes achieved by local government include proper sewage disposal and universal smallpox innoculation. The change has the potential to bring about local promotion of circumcision as a medical prophylaxis issue — if Councils can be persuaded of the benefits.

Maps

The UK is a member of the European Union but not a part of the Euro currency zone. An anomaly exists in as much as Gibraltar counts as part of South-West England for the purposes of elections to and representation in the EU parliament, but not otherwise.

Circumcision in the UK in the 20th century.

Prior to the introduction of the National Health Service after World War 2 (ie the late 1940s) people had to pay for all their medical needs including the birth of a baby and circumcision of a boy, if required. Unlike in the US, circumcision was not done within the first few days after birth, but later during the first year of life. Pre-NHS most mothers gave birth at home or in maternity nursing homes rather than hospitals, so there were no facilities for neonatal circumcision. Even today there is a reluctance in the UK to circumcise before the age of 3 or 4 months.

Circumcising a son therefore meant extra cost, and an additional visit to the doctor. Circumcision was seen as a luxury, and to the less well-off it often seemed an unnecessary expense. So ever since it became particularly popular in Victorian times, circumcision was always practiced more by the middle and upper classes. This was partly because they could afford it, partly because they were more educated and hence knew better of the benefits and partly because of peer pressure. Failing to circumcise was not doing the right thing by their son. A well-defined pattern developed with circumcision being more likely the higher up the social scale one’s parents were at the time of birth. This was a marked contrast to egalitarian Australia, where circumcision was routine for everyone, and parents would have to specifically state if they didn't want their son done.

Then, in 1949, Douglas Gairdner [1] wrote a paper in the British Medical Journal attacking routine circumcision. He studied the development of the foreskin and reported that it was not normally retractable until around age 3, so that no diagnosis of phimosis could be made until that age. That isn't an argument against prophylactic curcumcision, though. He also claimed that about 16 boys a year were dying from circumcision under age 5 (12 under age 1). That is a very much higher death rate than any subsequent study has found (though still only a tenth of the death rate from penile cancer at the time).

These figures are very rubbery, however. He knew that ~450,000 boys were born in each year of his study (1942-1947) but there were no records of the number of circumcisions. He estimated 20%, but both evidence from that time and subsequent studies show that this was too low, and the true rate was over 30% (see below). His deaths come from official records, where the category is "circumcision or phimosis" - so it also includes those who died from not being circumcised. Two other factors are relevant. Only one of his study years was truly post-war, and in that year the death rate plummeted. So bomb damaged hospitals and absence of doctors could have been a major factor. Also, he said that most deaths that had come to his attention were attributable to anaesthesia. In the US and Australia, with true neonatal circumcisions, general anaesthesia was never used.

When the National Health Service was formed, all necessary surgery became free of charge. Hospital birth also became the norm. However, circumcision had never been part of the birth 'package' so parents wanting it were not expecting it in the maternity ward. The combination of Gairdner's very influential paper and salaried NHS doctors who didn't earn anything from the operation meant that in practice, post 1950, parents didn't find it easy to get prophylactic circumcision, and rates declined.

Whilst the NHS in a small number of areas offers a circumcision service to meet demand from the Moslem population, anecdotal reports suggest that non-Muslim parents seeking circumcision for their sons are often turned away. Feedback from our readers would be much appreciated on this - contact us if you have any information. Private medicine has already stepped in to fill the vacuum and many circumcision clinics are operating around the UK.

Circumcision rates in the UK

In 1994 a survey was published by Penguin Books entitled “Sexual Behaviour in Britain” [2] giving the following information. The large sample size and the standard of the fieldwork probably make this the most reliable guide to the country’s circumcision rates at that time. The fieldwork took place between May 1990 and November 1991 as part of a much wider survey of sexual matters in the UK. (This, by the way, is the survey that Prime Minister Margaret Thatcher tried to stop, the very existence of the research proposal being the subject of a Cabinet Meeting reported in The Sunday Times 10th September 1989.)

UK Circumcision rates asa function of age group:

Age Group

Implied Year of Birth

% Circumcised

Sample size

16-24

1967 to 1975

12.5

1874

25-34

1957 to 1966

15.9

2111

35-44

1947 to 1956

26.4

1956

45-59

1932 to 1946

32.3

2049

These figures show that the '30s and '40s were the 'golden age' for circumcision in Britain. Both the present and former editors belong to this cohort, as do many of our contributors. One point that the present editor noticed while growing up was that Catholics were more likely to be circumcised than Anglicans, and the following table bears this out. The great traditional English Catholic public schools such as Ampleforth and Downside were largely foreskin-free zones.

UK Circumcision rates asa function of religious group:

Religion

% Circumcised

Sample size

Anglican

18.4

4120

Catholic

24.7

2011

Other Christian

22.1

863

Non-Christian

55.8

312

The table of ethnicities below does little to illuminate the situation. In 1994 the largest Asian population group in the UK was from the Indian subcontinent, so we are presumably seeing Pakistanis, Bangladeshis and Muslim Indians as circumcised, and Hindus and Sikhs as not. "Black" is also not terribly useful since the UK has many immigrants from the West Indies who would probably identify as "black" and not be distinguished from Africans.

UK Circumcision rates asa function of ethnic group:

Ethnic Group

% Circumcised

Sample size

White

20.9

7551

Black

34.1

150

Asian

35.3

165

Other

51.5

107

All men

21.9

7990

Other sources give similar figures. Writing in 1976, Gavin Weightmann [3] quotes two relevant studies. Stuart Carne, a London GP, reported in 1956 that 34.4% of 1,434 RAF recruits born between 1930 and 1936 were circumcised, with circumcision being more common among boys from public schools. Fast forward 10 years and Mc Carthy, Douglas and Mogford looked at 2,428 boys born in the first week of March, 1946, and found that 24% had been circumcised. This broke down to 21.9% for the sons of manual workers, and 38.8% for sons of salaried workers and professionals.

The 21st Century

The fragmented nature of the NHS statistical record-keeping system makes it difficult to obtain national data about rates of hospital circumcision. The Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust responded to a Freedom of Information Act enquiry concerning male circumcision as follows: “In 2009 the Trust performed 108 circumcisions on patients under 16 years of age and 117 circumcisions on patients 16 years of age or older.” [Disclosure ID 21926]

On its website the same Trust reports approximately 3000 births per year in its maternity unit. Assuming 50% male births and a constant churn of the population, this suggests a non-ceremonial circumcision rate of 108 per 1500 (7.2%) done on the basis of parental consent, with a further 117 per 1500 (7.8%) circumcised at age 16+. Given that the NHS does not, as a matter of general policy, perform elective circumcisions, these figures provide a very rough guide to the rate of circumcision, attributable to medical need or expediency, of about 15%. This implies that the NHS has funded circumcision of 15% of the male population after that point in time when the cost of each individual circumcision had (by virtue of patient age) already risen well above the neonatal cost. At a purely financial level, there would appear to be scope for studying whether offering prophylactic infant circumcision would be cheaper overall, especially considering the number of infant UTIs it would prevent.

The third National Survey of Sexual Attitudes and Lifestyles, carried out between 2012 and 2014, gives a snapshot of the population 30 years after the first survey (Wellings et al. [2]). Homfray et al. (2015) [4] report on the 4,060 men who were aged 16-44 years, and therefore mostly born post 1970. Overall 17.4% were circumcised. The table below shows the breakdown by age.

Age (years)

Est. birth year

Circumcised %

16-24

1987-1995

13.2

25-34

1977-1994

19.6

35-44

1967-1976

18.4

Note that the younger groups show a higher circumcision rate than in the 1994 survey, so that the overall trend is upwards. Also, the demographic born between 1967 and 1976, which then showed a 12.5% circumcision rate, now shows 18.4%, so many of that cohort have since got circumcised.

Ethnic Group

Circumcised %

White

12.0

Mixed

37.4

Asian / Asian British

48.8

Black / Black British

64.4

Other

28.8

Religion

Circumcised %

None

13.6

Christian

16.2

Muslim

87.6

Hindu

3.9

Other

21.5

As before, the ethnic and religious breakdowns are not terribly informative, though the huge increase in circumcision rate among those identifying as 'black' is noteworthy. It is also interesting that Christians are more likely to be circumcised than those with no religion.

The British Style

Each circumcising country tends to have its characteristic style. In the USA it is the Gomco, with its characteristic prominent 'perfect circle' scar. Back in the mid-20th century, most circumcisions in the UK were done by the 'tug and chop' method. The skin is pulled forward and cut in front of the glans. The outer skin retracts back down the shaft and the inner foreskin is pushed back to meet it. In a baby no sutures are used. The end results is a bare glans, with plenty of loose skin on the shaft. In erection the scar will be half-way down the shaft, very inconspicuous and somewhat irregular. The skin will still have a centimetre or two of totally free mobility. It is very easy indeed to masturbate that sort of penis, giving the lie to the idea that circumcision hinders masturbation.

Sometimes more skin was left, so that the glans was partially covered before puberty, though it always emerged as the boy grew up. However there are also plenty of reports of a minority with tight circumcisions, some of them dead tight, Australian-style. These were probably done by the technique described in 1912 by the distinguished surgeon Sir Willian Whitla[5]:

The elongated prepuce is pulled forwards and clamped by a pair of forceps applied ... in an oblique direction forwards and downwards, after which the prepuce is cut off by the sweep of a sharp [scalpel] in front of the blades, as the glans lies safely behind the latter. The lining membrane of the remaining prepuce is next slit up the dorsal aspect of the glans almost as far as the corona and neatly trimmed, after which the remaining narrow frill or collar of mucous membrane is stitched .... to the skin margin. When the original incision is skilfully made, a pointed piece of skin remains, which can be sutured over the triangular area below the frenum.

That sort of circumcision is not so easy to masturbate and maybe that was Whitla's intention in 1912. But nature always found a way! Schoolboys, at least back in those days, were very keen to investigate the different sorts of penis. Circumcised ones were called roundheads, after the Parliamentary side in the Civil War who had close-cropped hair, while foreskinned boys were cavaliers, after their long-haired Royalist opponents. The differences between different examples of the same sort were equally interesting, and this is all delightfully described in Brian Aldiss' book "The Hand-Reared Boy" (see our Reviews page).

The British Natural Penis

Something that surprises many people in northern European countries is that in Britain it is considered normal that the foreskin of a natural (uncircumcised) man does not cover the glans. Back in the 18th century John Cleland, in his erotic novel Fanny Hill, describes the hero's penis as "half-capt" when flaccid after his first intercourse with Fanny (who had, rather improbably, remained a virgin up to that point). Fast forward to 1953 when the Army doctor T.E. Osmond reported on 1,095 men he had examined [6]. 34% were circumcised, which agrees pretty well with other estimates at that time. Of the remainder, 58% had foreskins which Osmond described as "normal" - not completely covering the glans. Forward another 20 years. Dr Robert Chartham, in his book "Advice to Men" [7] reported on a survey of 2,500 men in which "less than half (45%) have foreskins that completely cover the head of the relaxed penis, whereas in 32% the foreskin covered only half the head and in 23% did not cover it at all." Chartham also reported on a smaller survey of his own. Only 9 out of 100 men had a covered glans, though a further 18 had foreskins which could cover the glans except that they wore it permanently retracted.

Is this atypical, and if so, why? Certainly the Editor's own survey in Australia found many more covered knobs (see our surveys page.) and this was attributed to an environment where circumcision was the norm, so that parents did not know how to teach their sons how to manage a foreskin. Looking at the male nude photographs of Baron von Gloeden suggests that in late 19th century Italy only around 20% of sexually mature teenagers and adults had a covered glans, so that the British situation is nothing out of the ordinary. So why are some northern countries different? It seems unlikely that there is any racial difference within the melting pot of modern Europe, so the difference must be cultural. In the UK it was the custom for parents to (or nannies in more affluent families) to retract a baby's foreskin when bathing him, and later to encourage the boy to do the same every bathtime. By age 9 or 10 retraction became a competitive matter among schoolboys, and you were a loser if you couldn't get it back. Certainly it was the ones which were easily retracted before puberty which tended not have coverage afterwards.

Circumcision and Britain’s colonial history

Britain's takeover of India is surely unique in that a trading company became de facto rulers of a huge country for over 100 years. The "Governor and Company of Merchants of London trading into the East Indies" obtained a Royal Charter from Queen Elizabeth the 1st in 1600 to trade into India and the East Indies. India at that time was ruled by the Mughal empire which was Muslim and spoke Farsi (Persian). In 1612, the "London Company" obtained a trade agreement with the Mughal Emperor Nuruddin Salim Jahangir (r. 1605-1627) that gave the company exclusive rights to reside and establish factories in Surat and other areas. The Portuguese, Dutch and French had similar ideas - in the end the Dutch settled on the East Indies (present day Indonesia) but there was rivalry, and sometimes warfare, between British, French and Portuguese interests.

The monopoly of the 'old' or 'London' company was challenged and in 1694 Parliament revoked the monopoly and the 'new' or 'English' company (the English Company Trading to the East Indies) set up in opposition. By 1712 the two companies merged to form the 'United Company of Merchants of England Trading to the East Indies', or the East India Company in general parlance. The monopoly was back, and the powerful new company established a private army and by 1757 became effectively the rulers of India, a situation which continued until the British Government took over in 1858. One factor in this takeover was a collapse in the Mughal Empire. For three centuries the Muslim Mughal rulers had exercised a benign and tolerant rule, allowing all faiths to continue, but the rule of 'Aurangzeyb changed this. He was a mean-spirited (and possibly dim-witted) zealot who attempted to convert all India to Islam. With his death in 1707 the Mughal rule began to fall apart, creating openings for outsiders.

That is the background. The account that follows is largely based on "The rape of India - a biography of Robert Clive" [7] by Allen Edwardes, the nom de plume of a writer of erotica, but well-researched erotica, whose avowed intent is to put the sex back into history. It is hard to dispute the merits of this, and he cites more sources than many other historians.

Circumcision had many advantages for the East India Company. Circumcised men were more likely to be accepted as envoys at the Mughal Court than uncircumcised men, a fact first proved in the 17th century when two English musicians, Lancelot Canning (spinet) and Robert Tully (cornet) sought to bring English music to the Mughal court. They were only accepted after being circumcised and given Muslim names, after which they were handsomely rewarded and became valuable intermediaries between the EIC and the Court. In 1686 strife broke out betweem the EIC and Emperor 'Aurangzeyb over the extortionate jizeh (uncircumcision) tax imposed on infidels. Josiah Child, director od the EIC, sent two of his top negotiators to intervene. Abraham Navarro, the interpreter, was Jewisj and George Weldon, the chief negotiator, was also circumcised. In Weldon's account:

We were received at Courte with our hands tyed by a Sashe before us, whereupon ye Greate Mogull withdrew us into a Privie Chamber, where he order'd an Eunuque to let down our breeches, that he might satisfye himself that we were both of us Circumcyzed, and therefore fitting Spokesmen of an Uncircumcyzed Race, any member of which who is thus mutillated must command especiall Attention & by ye Moores, who regard Uncircumcision as Infidellish and uncleane, hence reprehensible, and despize & mistrust such as are not purifyed in ye Flesh. So satisfyed that we were thus sanctifyed, he ordere'd our Hands to be untyed, and treated us as Honourable Men.

(Nobody writes sentences like that anymore ...) The end result was that in 1690 an agreement was struck that the EIC could trade tax-free for an annual fee of 30,000 rupees. Circumcision was clearly a valuable negotiating tool, and many of the early Merchant Adventurers had themselves done for this reason.

From 1661 the authorities of the London Company at Fort St George had ordered that "All Cadettes shall be bodily examined, as in ye Military Services, agaynst any irregular condition of ye Genitories." If a cadet could not "strip his yard" the surgeon was ordered to "clip ye Skin entire". (Two of the members of the council which enacted this rule were themselves circumcised). Circumcision reduced the risk of infection, whether from the steamy tropical climate or from sexual encounters. All types of sex were freely available and naturally teenage cadets were going to take advantage of this. The third benefit of being circumcised in that environment was that being captured by Mughal rebels usually resulted in forcible circumcision of anyone who still had a foreskin. Even a 17th century doctor was preferable to what happened to these unfortunates!

With the coming of the 'New' company, and the subsequent merger to form the East India Company, this rule remained in force, as one rather rebellious cadet was about to find out.

Robert Clive

Robert Clive was born into the 'squirearchy' in 1725, son of a squire who was also a barrister and MP. He was a rebellious child, eventually becoming what we would now call a juvenile delinquent. At 17, his despairing family sent him off to enrol with the East India Company as a cadet 'writer' (clerk). His voyage out, in the days of sail, was eventful, including running aground in Brazil, and it was nine months later that he arrived at Fort St George, near what was to become Madras (now Chennai). There he was duly examined by the Company's medical officer, Dr John Rae, who has left a comprehensive Journal of his time in India. He was found to have a severe phimosis, and was therefore circumcised, despite his protests. "By God, had I known I was come out here to be clipped, I'd have forsworn pork and procured me a skullcap!" In spite of this, Clive, the consummate politician, subsequently used his circumcised status to great advantage in his dealing with the Mughals, and later stated "I am proud to bear this mark of an empire which we may one day rule ourselves".

Robert Clive, 1st Baron Clive of Plassey, meeting with Mir Jafar after the battle of Plassey, by Francis Hayman

But in the short term Clive, even when healed, found the sensitivity of his glans, newly exposed after 18 years, hard to take. British close-fitting breeches were too stimulating, so he adopted Mughal loose trousers. (This was actually an advantage when he had to escape a besieged Fort St George disguised as a Muslim). He continued to masturbate, which, as Dr. Rae ruefully stated, "Circumcision is alleged to cure". He apparently got one Chuleel (presumably an Indian manservant) to fellate him regularly. But the escape from Fort St George led him to realize that the French had to be opposed and that in turn led him to join the (company) army, a move which suited his temperament and took him on to great things. His rise was meteoric, and after the Mughal rebellion of 1756-57 he became Governor of the Presidency of Fort William, effectively the ruler of India.

Warren Hastings

Warren Hastings was born in 1732 into a formerly well-off family which had fallen on hard times. At the age of 18 he joined the British East India company, like Clive, as a cadet clerk. Unlike Clive, his ambition did not involve belligerence, and he rose up by virtue of hard work. He learned Farsi (the language of the Mughals), as well Hindi and Bengali (the languages of the Indian people). These stood him in good stead and his career moved steadily ahead, until, in 1752, he was promoted to a position at Kasimbazar, in Bengal. Here things were happy until the death of the moderate ruler Nawab Alivardi Khan in 1756. This precipitated a revolt which led to the infamous Black Hole of Calcutta, where many of British garrison died of asphyxiation. Kasimbazar surrendered, and Hastings was taken prisoner and forcibly circumcised. He was held in the Bengali capital Murshidabad, where for a while he acted as an intermediary but (fearing for his life) he escaped to the island of Fulta. There he met, and married, Mary Buchanan whose husband had died in Calcutta. (Presumably by that stage things had healed).

Warren Hastings and his second wife Maria, in later and happier times.

In January 1757 Clive arrived with an army from Madras, and Hastings joined up. He and Clive got on well together in spite of their different temperaments, helped by Hasting's command of the local languages (and perhaps by the common bond of circumcision). They retook Calcutta, and their victory in the Battle of Plassey led to Clive becoming ruler of India. Much later (1772) Hastings was to take this position and in 1774 he became the first Governor General of India. Sadly, by this time Mary had died, and (after a period of cohabitation and a notorious divorce) he married his second wife Maria, a German baroness.

Epilogue

Both Clive and Hastings became extremely wealthy, and were showered with honours. However both had made enemies and after they returned to England both were called to account before the House of Lords. Both were totally exonerated though in Hasting's case it took 8 years.

The East India Company effectively ceased to exist after the British government took over the rule of India in 1858. But given that so many squires' sons had served their term there, how much influence did their policies have on circumcision in England?

Circumcision and the Royal Family

At the time of the birth of Prince Charles in November 1948, it was routine for the medical circumstances of royalty to be disclosed. Such disclosure was very public; a notice would be affixed to the gates of Buckingham Palace on each occasion when the Royal Family had reason to consult a member of the medical profession. Thus it is no secret that Charles was circumcised shortly after birth by Dr. Jakob Snowman, who was both a leading urologist and a certified mohel.

The situation regarding the next generation was, at first, less clear. By the time of Prince William’s birth in June 1982, more normal standards of privacy had been accorded to the Royals. At the time the rumour was that his mother, Her Royal Highness the Princess of Wales, was strongly opposed to circumcision and that, despite the objections of both the Queen and the Queen Mother, both Prince William and his younger brother Prince Harry remained intact as children. However, the respected author Ingrid Seward, in her biography William & Harry : A Portrait of Two Princes[9], published in June 2003, writes (about William):

There were to be no dummies, no use of ‘pacifiers’ as the Americans call them. If he cried it was his mother’s finger that would calm him and she intended, she said, ‘always to be there to provide it’.

She agreed to William, and later Harry, being circumcised in keeping with royal tradition but turned her nose up at Charles’s suggestion that the boy should be called by the ancient name of Arthur. ‘Too old-fashioned’, she said.

Should we believe Ingrid Seward’s account? Probably. She has written about the British royal family for the best part of two decades, the author of eight books on the subject as well as being editor-in-chief of Majesty magazine. A respected source of information about the privileged lives of the royal families of the world, Ms. Seward is regarded by some as a chosen channel for deliberate leaks of nominally confidential information. What is more, there is a paparazzo photograph of Prince William taking a leak (which we absolutely will not post) in which he appears to be circumcised.